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Open Access Research article

How much can we gain from improved efficiency? An examination of performance of national HIV/AIDS programs and its determinants in low- and middle-income countries

Wu Zeng1*, Donald S Shepard1, Jon Chilingerian1 and Carlos Avila-Figueroa2

Author affiliations

1 Schneider Institutes for Health Policy, Heller School, MS 035, Brandeis University, Waltham, MA 02454-9110, USA

2 Abt Associates, 4550 Montgomery Ave., Suite 800 North, Bethesda, MD 20814, USA

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Citation and License

BMC Health Services Research 2012, 12:74  doi:10.1186/1472-6963-12-74

Published: 24 March 2012



The economic downturn exacerbates the inadequacy of resources for combating the worldwide HIV/AIDS pandemic and amplifies the need to improve the efficiency of HIV/AIDS programs.


We used data envelopment analysis (DEA) to evaluate efficiency of national HIV/AIDS programs in transforming funding into services and implemented a Tobit model to identify determinants of the efficiency in 68 low- and middle-income countries. We considered the change from the lowest quartile to the average value of a variable a "notable" increase.


Overall, the average efficiency in implementing HIV/AIDS programs was moderate (49.8%). Program efficiency varied enormously among countries with means by quartile of efficiency of 13.0%, 36.4%, 54.4% and 96.5%. A country's governance, financing mechanisms, and economic and demographic characteristics influence the program efficiency. For example, if countries achieved a notable increase in "voice and accountability" (e.g., greater participation of civil society in policy making), the efficiency of their HIV/AIDS programs would increase by 40.8%. For countries in the lowest quartile of per capita gross national income (GNI), a notable increase in per capita GNI would increase the efficiency of AIDS programs by 45.0%.


There may be substantial opportunity for improving the efficiency of AIDS services, by providing more services with existing resources. Actions beyond the health sector could be important factors affecting HIV/AIDS service delivery.

HIV/AIDS; Performance; Efficiency; Governance; Data Envelopment Analysis